Circumventing 'free care' and 'shouting louder':Using a health systems approach to study eye health system sustainability in government & mission facilities of north-west Tanzania.

BACKGROUND: Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. In the specialist area of eye health, international and domestic Christian FBOs have been important contributors as service providers and donors, but they are also commonly critiqued as having developed eye health systems parallel to government structures which are unsustainable. METHODS: In this study, we use a health systems approach (quarterly interviews, a participatory sustainability analysis exercise and a social network analysis) to describe the strategies used by eye care practitioners in four hospitals of north-west Tanzania to navigate the government, church mission and donor rules that govern eye services delivery there. RESULTS: Practitioners in this region felt eye care was systemically neglected by government and therefore was 'all under the NGOs', but support from international donors was also precarious. Practitioners therefore adopted four main strategies to improve the sustainability of their services: (1) maintain 'sustainability funds' to retain financial autonomy over income; (2) avoid granting government user fee exemptions to elderly patients who are the majority of service users; (3) expand or contract outreach services as financial circumstances change; and (4) access peer support for problem-solving and advocacy. Mission-based eye teams had greater freedom to increase their income from user fees by not implementing government policies for 'free care'. Teams in all hospitals, however, found similar strategies to manage their programmes even when their management structures were unique, suggesting the importance of informal rules shared through a peer network in governing eye care in this pluralistic health system. CONCLUSIONS: Health systems research can generate new evidence on the social dynamics that cross public and private sectors within a local health system. In this area of Tanzania, Christian FBOs' investments are important, not only in terms of the population health outcomes achieved by teams they support, but also in the diversity of organisational models they contribute to in the wider eye health system, which facilitates innovation

Review essay: prospects for old-age income security in Hong Kong and Singapore

This review shows that Hong Kong and Singapore face a distinct and serious challenge to old-age income security due to their mix of public pension provision and intergenerational family support. They are among the fastest ageing societies internationally and will be the oldest in Asia after Japan by 2030. Yet their public pensions remain weak. Defined contribution pensions, even for full-career workers, are projected to replace just 17% of net lifetime average earnings in Singapore and 41% in Hong Kong, compared to 70% across the OECD countries. Instead, older persons in Singapore and Hong Kong depend mainly on their adult children for income security in the form of co-residence and cash transfers. More than half of them live with adult children. In Singapore, more than two-thirds receive financial support from the younger generation, compared to just 5% on average in Europe. Current welfare theory would suggest that Singapore and Hong Kong portray an extreme variant of welfare regime where the state's role is more limited than in the liberal regime and the family's role more central than in the Southern European regime. The sustainability of current old-age income security arrangements is therefore particularly vulnerable to new social risks that threaten the stability of traditional family structures. Already co-residence and financial support from adult children are declining. A fuller assessment of the prospects for old-age income security must focus on the interaction of pension policy and family support for elderly persons in different gender and income groups